Treatment of Catatonic Stupor with Combination of Modified Electroconvulsive Treatment and Olanzapine

[Electroconvulsive therapy in people with intellectual disability]

Electroconvulsive therapy (ECT) is a highly effective treatment option for severe mental illness. Although people with intellectual disability (ID) have similar prevalence rates of mental disorders in comparison to the general population their access to ECT remains challenging. A systematic literature review was carried out on treatment with ECT in patients with ID and a case report on a patient with ID who underwent ECT is presented, to highlight a typical clinical routine. A total of 100 articles with 208 different case reports were retrieved. In summary, the results underline the effectiveness of ECT in people with ID, with side effects comparable to those in the general population. The ECT is effective in the treatment of severe affective and psychotic disorders and particularly in people with catatonia. The use of ECT can improve the patient's mental health and quality of life and is often a life-saving treatment option. The prophylaxis of relapses should be included as early as possible in the planning process. Providing an easy access to ECT treatment for people with ID is corroborated by its effectiveness and is in line with the right to equal treatment in accordance with article 25 of the United Nations Convention on the Rights of Persons with Disabilities.

First known case of catatonia due to cyclosporine A-related neurotoxicity in a pediatric patient with steroid-resistant nephrotic syndrome

BACKGROUND

Catatonia is a neuropsychiatric syndrome characterized by diverse psychomotor abnormalities, including motor dysregulation and behavioral and affective disturbances. Once thought to occur primarily in the context of schizophrenia, recent data suggest most cases of catatonia develop in individuals with depressive or bipolar disorders. Moreover, catatonia may ensue in general medical and neurological conditions, as well as due to a variety of pharmaceuticals, drugs of abuse, and toxic agents. At one time considered rare in pediatric patients, evidence now suggests catatonia is both underrecognized and undertreated in this population, where it carries an elevated risk of morbidity and mortality. Here we present the case of a child with steroid-resistant nephrotic syndrome who developed catatonia due to cyclosporine A-related neurotoxicity.

CASE PRESENTATION

A 9-year-old African-American boy with no psychiatric history and a 9-month history of nephrotic syndrome due to focal segmental glomerulosclerosis was admitted to the local children's hospital for management of mutism, posturing, insomnia, gait abnormalities, and somatic delusions. Seven days prior to admission, his cyclosporine plasma concentration was elevated at 1224 ng/mL (therapeutic range: 100-200 ng/mL). Upon admission, cyclosporine was discontinued and psychiatry was consulted, diagnosing catatonia. The patient subsequently received propofol 80 mg IV resulting in a transient lysis of catatonia. Over a lengthy hospitalization, the patient's catatonia was initially treated with lorazepam, quetiapine being added later to target psychosis. All signs and symptoms of catatonia resolved, and the patient was eventually tapered off both lorazepam and quetiapine with no return of symptoms more than 6 months later.

CONCLUSIONS

To our knowledge, this case represents the first reported instance of cyclosporine A-induced catatonia in a patient with steroid-resistant nephrotic syndrome. It illustrates the importance of maintaining vigilance for signs and symptoms of cyclosporine A-related neurotoxicity (including catatonia) in patients with steroid-resistant nephrotic syndrome. In addition, it highlights the challenges faced by clinicians in jurisdictions that prohibit the use of electroconvulsive therapy in pediatric patients.

A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy

BACKGROUND

Ritualistic behaviors are common in obsessive compulsive disorder (OCD), while catatonic stupor occasionally occurs in psychotic or mood disorders. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms. The syndrome usually represents a specific diagnosis, as in the case of the 10th edition of the International Classification of Diseases (ICD-10) or the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, symptom-based diagnosis can result in misdiagnosis and hinder effective treatment. Few cases of ritualistic behaviors and catatonic stupor associated with schizoaffective disorder have been reported. Risperidone and modified electroconvulsive therapy (MECT) were effective in our case.

CASE PRESENTATION

A 35-year-old man with schizoaffective disorder-depression was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled us to make the diagnosis of OCD. Sertraline add-on treatment exacerbated the psychotic symptoms, such as pressure of thoughts and delusion of control. In the presence of obvious psychotic symptoms and depression, schizoaffective disorder-depression was diagnosed according to ICD-10. Meanwhile, the patient unfortunately developed catatonic stupor and respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone were administered. As a result, we successfully cured the patient with the abovementioned treatment strategies. Eventually, the patient was diagnosed with schizoaffective disorder-depression with ritualistic behaviors and catatonia. Risperidone and MECT therapies were dramatically effective.

CONCLUSION

Making a differential diagnosis of mental disorders is a key step in treating disease. Sertraline was not recommended for treating schizoaffective disorder-depression according to our case because it could exacerbate positive symptoms. Controversy remains about whether antipsychotics should be administered for catatonic stupor. However, more case studies will be needed. Risperidone with MECT was beneficial for the patient in our case.

Movement disorders in catatonia

Catatonia is a complex neuropsychiatric syndrome characterised by a broad range of motor, speech and behavioural abnormalities. 'Waxy flexibility', 'posturing' and 'catalepsy' are among the well-recognised motor abnormalities seen in catatonia. However, there are many other motor abnormalities associated with catatonia. Recognition of the full spectrum of the phenomenology is critical for an accurate diagnosis. Although controlled trials are lacking benzodiazepines are considered first-line therapy and N-Methyl-d-aspartate receptor antagonists also appears to be effective. Electroconvulsive therapy is used in those patients who are resistant to medical therapy. An underlying cause of the catatonia should be identified and treated to ensure early and complete resolution of symptoms.

Catatonia in patients with autism: prevalence and management

Although recent studies have shown that catatonia can occur in patients with autism spectrum disorders (ASDs), the overlap of the behavioral features between these disorders raises many diagnostic challenges. In fact, in clinical practice it is common to misinterpret catatonic symptoms, including mutism, stereotypic speech, repetitive behaviors, echolalia, posturing, mannerisms, purposeless agitation and rigidity, as features of ASDs. The current medical treatment algorithm for catatonia in ASDs recommends the use of benzodiazepines. Electroconvulsive therapy (ECT) is indicated when patients are unresponsive, or insufficiently responsive, to benzodiazepines. Other pharmacological options are also described for the treatment of catatonic patients resistant to benzodiazepines and ECT, and there is evidence for the effectiveness of a psychological treatment, co-occurring with medical treatments, in order to support the management of these patients. In this article we provide a summary of studies exploring catatonia in ASDs and our clinical experience in the management and treatment of this syndrome through the presentation of three brief case studies. Moreover, we review the mechanisms underlying symptoms of catatonia in ASDs, as well as the diagnostic challenges, providing an outline for the management and treatment of this syndrome in this clinical population.

[Acute catatonia: Questions, diagnosis and prognostics, and the place of atypical antipsychotics]

INTRODUCTION

Acute catatonia is a non-specific, relatively frequent syndrome, which manifests itself through characteristic motor signs that enables its diagnosis. It occurs in association with mood disorders, psychotic disorders and several somatic or toxic diseases. Its short-term prognosis is of paramount importance. Without effective treatment, it is associated with high mortality. Despite the vital risk inherent in this disorder, it is not recognized as an independent diagnostic category by international rankings, which makes its diagnostic detection difficult and consequently does not allow adequate therapeutic care. However, if benzodiazepines and electroconvulsive therapy have proved effective in the treatment of acute catatonia, the role of atypical antipsychotics remains controversial. In fact, despite the progress made by the DSM-IV-TR and CIM 10 by the recognition of the etiologic diversity of catatonia, we deplore the absence to date of a consensus on clinical management and therapy of catatonia, which constitutes a source of confusion for practitioners in their approach to catatonic patients. To illustrate the difficulty in supporting these patients, we report here a clinical vignette.

CLINICAL FEATURES

Mr. M. aged 21, without psychiatric history, has shown a functional acute psychotic episode involving a delirious and hallucinatory syndrome associated with a marked catatonic dimension. Olanzapine was initiated at a dose of 10mg/d on the nineth day of hospitalization; the clinical picture was complicated by a malignant catatonia justifying the halt of olanzapine and the institution, in intensive units, of 15mg per day of lorazepam. After 72hours, the patient has not responded to this treatment. ECT was expected, but the patient died on the 12th day.

DISCUSSION

This case raises a threefold question: the crucial issue of immediate vital prognosis, that of the truthfulness of the positive diagnosis of this psychotic table and finally the issue of therapeutic care, primarily the well-founded or otherwise use of an atypical antipsychotic for the treatment of this type of psychotic disorder. For Mr. M., the clinical diagnosis that he has shown, according to the DSM IV-TR, is brief psychotic disorder "temporary diagnosis". This diagnosis - brief psychotic disorder - does not actually allow for a specific clinical approach to this type of psychotic table. The immediate vital prognosis inherent in the catatonic dimension may not be properly evaluated and the therapeutic conduct may miss the application of the specific treatment of the catatonic syndrome. The proper diagnosis for this type of psychotic disorder would be "catatonia" as proposed by Taylor and Fink, instead of "brief psychotic disorder" if the international rankings have included this disorder as a separate and independent diagnosis. The identification by international rankings of the catatonic syndrome as an independent diagnostic category seems essential for clinicians to allow: its clinical detection, the establishment of a syndromic diagnosis of catatonic disorder, appropriate prognostic evaluation and finally, the application of a suitable therapeutic strategy. Conventional treatment, benzodiazepine- and/or ECT-based, can solve the catatonic episode in a few days, irrespective of its etiology and its severity. Moreover, while all authors agree that conventional antipsychotics may induce a catatonic state or worsen a preexisting catatonia into a malignant catatonia and should thus be avoided for catatonic patients or with prior catatonic episodes, recent data from the literature emphasize the frequent and successful use of atypical antipsychotics, including olanzapine, in various clinical forms of benign catatonia. However, our patient did not respond to treatment with olanzapine and got even more complicated. Was the malignant catatonia that this patient has shown induced by olanzapine ? The answer to this question seems difficult since some authors report the efficacy of olanzapine in malignant catatonia. We wonder if we should have kept olanzapine and strengthen its dosage like Cassidy et al. in 2001 and Suzuki et al. in 2010 for the treatment of the malignant form constituted in this patient rather than having stopped it and used lorazepam as indicated by Taylor and Fink in 2003.

IN CONCLUSION

The non-recognition of catatonia as an independent entity, the lack of a therapeutic consensus and the pending issue on the safety and efficacy of atypical antipsychotics in the treatment of catatonia are at the origin of the difficulties of therapeutic support of catatonic patients.

A case of catatonia due to posterior reversible encephalopathy syndrome treated successfully with antihypertensives and adjunctive olanzapine

Catatonia is a distinct neuropsychiatric syndrome with prominent motor manifestations. Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic syndrome usually precipitated by malignant hypertension. Given the overlapping neuropathology in both syndromes, we present a case of catatonia precipitated by PRES, with full resolution of the former after successful treatment of the latter.

Prolonged catatonic stupor successfully treated with aripiprazole in an adolescent male with schizophrenia: a case report

We present the case of a fifteen-year-old adolescent male with schizophrenia who had long-term catatonic stupor and was successfully treated with aripiprazole. The onset of his stupor manifested rapidly after experiencing prodromal symptoms for two months. He was left untreated without adequate food ingestion for three weeks because of his parents' religious faith, and was severely dehydrated and malnourished upon admission to our hospital. After his physical recovery, treatment with risperidone (0.5-2.0 mg, 5 weeks) was started. However, hypersedation occurred, and the risperidone was switched to aripiprazole, with dose increases up to 18 mg/day (5 months). As a result, he recovered from his totally noncommunicative state. Aripiprazole, which has a unique pharmacological mechanism of action distinct from other atypical antipsychotics and an excellent safety profile, may be effective in the treatment of some schizophrenic patients with stupor, which sometimes carries a risk of physical debilitation and requires special attention due to the risk of adverse drug reactions.

Safety of the electroconvulsive therapy-ziprasidone combination

In clinical practice, a nonnegligible proportion of patients with mood or psychotic disorders undergo electroconvulsive therapy (ECT) concomitantly with pharmacotherapy. Ziprasidone, a combined serotonin and dopamine receptor antagonist, is a second-generation antipsychotic agent with a lower incidence of extrapyramidal motor symptoms and prolactin elevation and a safer profile of adverse effects on plasma lipids, glucose levels, and body weight than other antipsychotics. To the best of our knowledge, there are as yet no available reports on the safety of the ECT-ziprasidone combination. We report here on a series of 8 female inpatients who underwent ECT while receiving ziprasidone (20-80 mg/d) as part of their regimen. Seven patients were treated for major depressive episode in the context of unipolar major depressive disorder (n = 5) or of bipolar disorder I (n = 2), whereas 1 patient was treated for exacerbation of schizophrenic symptoms. In all cases, the combination was well tolerated with only minimal adverse effects and unremarkable changes in corrected QT interval.

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

[Patient with encephalitis presenting with olanzapine-responsive malignant catatonia]

We report the case of a 29-year-old man, who could not remember some words of Kanji and showed emotional instability. Magnetic resonance imaging (MRI) scan of his brain appeared normal. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis. An electroencephalogram (EEG) showed slow activities in both frontal regions of the brain. He was diagnosed as acute encephalitis. On his fourth hospital day, he was found to be catatonic and showed mutism, akinetism, and catalepsy. On the ninth day, he showed hyperpyrexia, muscle rigidity, difficulty in swallowing, respiratory insufficiency, and rhabdomyolysis (creatine phosphokinase (CK), 3038 IU/l). He was diagnosed as malignant catatonia. Intravenous administration of acyclovir, high-dose methylprednisolone, antibiotics, diazepam, and dantrolene sodium was not effective. After initiating oral administration of olanzapine, his condition improved.

The safety of the electroconvulsive therapy-aripiprazole combination: four case reports

In clinical practice, a proportion of patients with psychotic or mood disorders are treated with electroconvulsive therapy (ECT) while receiving concomitantly antipsychotic and/or other psychotropic agents. Aripiprazole is a second-generation antipsychotic that seems to have a favorable side-effect profile. However, to the best of our knowledge, there are, as yet, no available reports on the safety of ECT-aripiprazole combination. We report the cases of 4 female inpatients--3 suffering from major depression and 1 from schizophrenia--who underwent ECT--1 of them twice--while receiving aripiprazole (10-15 mg/d), as part of their regimen. In all cases, the combination was well tolerated and only minimal side effects were reported.

Postictal catatonia in a schizophrenic patient and electroconvulsive treatment

Catatonic state has been related to variable medical, neurological, and psychiatric disorders. Although it is commonly associated with schizophrenia, epilepsy presenting as catatonialike seizures or ictal catatonia was rarely reported. Moreover, the coexistence of schizophrenia and epilepsy in a patient complicates the diagnosis and management. Here we report a case of postictal catatonia in a patient with schizophrenia who was successfully treated by electroconvulsive treatment, and in this context, we aimed to review the therapeutic effect of electroconvulsive treatment in postictal catatonia.

Transient splenial lesion of the corpus callosum after acute withdrawal of antiepileptic drug: a case report

Transient lesions at the splenium of the corpus callosum (SCC) have been reported after withdrawal of specific antiepileptic drugs (AED), though the pathophysiology of the lesions remains unclear. We examined and treated a schizophrenic patient who developed a transient SCC lesion after withdrawal of the AED, carbamazepine. Interestingly, the SCC lesion was accompanied by the onset of diabetes insipidus, a state of arginine-vasopressin (AVP) insufficiency. Because carbamazepine is shown to potentiate the effect of AVP, our case suggests that an insufficiency of AVP followed by withdrawal of AED could contribute to the pathogenesis of a transient SCC lesion.